13. Elbow, Forearm, Wrist, and Hand

what are the bones in the elbow?

humerus

ulna

radius

what are the joints of the elbow?

humeroulnar

humeroradial

proximal radioulnar

what are the ligaments in the elbow?

ulnar (medial) collateral ligamet

annular ligament

radial (lateral) collateral ligamet

what muscles cause elbow flexion?

* biceps brachii
* brachialis
* brachioradialis

what muscles cause elbow extension?

* triceps brachii
* anconeus

what should the history questions address?

* overuse
* sudden overextension
* throwing
* other stressful activities

are nerve symptoms an important clue to MOI?

YES

what are some other key points for elbow and forearm assessment?

* observe how the athlete is holding their arm
* when palpating and performing ROM/special tests, keep forearm position in mind
* there are very few special tests of the elbow

what are **acute** injury prevention methods?

* avoid FOOSH
* wear appropriate bracing / padding / protective equipment

what are **chronic** injury prevention methods?

* limit reps
* ensure appropriate mechanics
* select and use equipment that is appropriate for a specific skill level
* maintain strength of elbow dynamic

why is the olecranon bursa more prone to acute or chronic injury?

because of its superficial location

MOI → olecranon bursitis

* direct blow
* falling on the tip of the bent elbow

signs of injury → olecranon bursitis

* pain, marked swelling, and point tenderness
* swelling will appear almost spontaneously and without the usual pain and heat

MOI → elbow sprains

HYPEREXTENSION or a force that bends or twists the lower arm outward

care → elbow sprains

* **cold pack** & **pressure bandage for at least 24hrs**
* sling support fixed at **90˚ of flexion**
* progressively aid the elbow in r**egaining full ROM**
* **grade 3 is usually surgical**
* athlete should **gradually progress the number of throws** in throwing activities

what is the other name for lateral epicondylitis?

tennis elbow

MOI → lateral epicondylitis

repetitive forceful **EXTENSION** of the wrist

signs of injury → lateral epicondylitis

* **Aching pain** in the region of the lateral epicondyle during and **after activity, pain gradually increases over time**
* **Pain on resisted extension of the wrist** and **full extension of the elbow**

care → lateral epicondylitis

POLICE, NSAIDs, rehab focusing on muscular strength, counterforce brace, correct mechanics

another name for medial epicondylitis?

Golfer’s elbow

MOI → medial epicondylitis

repeated forceful **FLEXION** of wrist

signs of injury → medial epicondylitis

* Pain occurs around the medial epicondyle during **forceful wrist flexion** and m**ay radiate down the arm**
* **Point tenderness** and **mild swelling**
* Pain with **active wrist movement**

care → medial epicondylitis

rest, cryotherapy, NSAIDs, counterforce brace

MOI → elbow osteochondritis dissecans

UNKNOWN

signs of injury → elbow osteochondritis dissecans

* **sudden pain** and **locking** of the elbow joint
* ROM usually returns in a few days
* **swelling, pain, and crepitus** may also occur

care → elbow osteochondritis dissecans

repeated episodes of locking may warrant surgical removal of the loose bodies

→ without removal, traumatic arthritis may develop

MOI → ulnar nerve injuries

nerve friction or recurrent dislocation

Signs of injury → ulnar nerve injuries

usually respond with a **paresthesia of 4th and 5th fingers**

care → ulnar nerve injuries

* **Conservative management**, which includes avoiding aggravation of the nerve (consider mechanics or causes of inflammation)
* **Surgery may be necessary** if stress on the nerve cannot be avoided

MOI → elbow dislocation

FOOSH with the elbow **EXTENDED** or by a severe twist while the elbow is flexed

signs of injury → elbow dislocation

* May be **displaced backward, forward, or laterally**
* **Rupturing and tearing** of most of the stabilizing ligamentous tissue accompanied by **bleeding and subsequent swelling**
* %%**Severe pain and disability**%%
* Complications may include **injury to the major nerves and blood vessels**
* @@**Wrist should be checked for a pulse**@@

MOI → Elbow Fracture

* FOOSH or fall on flexed elbow
* direct blow to the elbow

signs of injury → Elbow Fracture

* visual deformity
* hemorrhaging, swelling, and muscle spasms in the injured area

Care → Elbow Fracture

typical fracture care with some urgency to prevent Volkmann’s contracturewh

What is Volkmann’s Contracture?

rapid swelling → an extremely serious and often irreversible condition

what are the bones of the forearm?

radius and ulna

the ulna is thought to be a direct extension of the ______

humerus → long, straight, **larger at its upper** than lower end

the radius is considered an extension of the _____

hand → **thicker at its lower** than upper end

what are the joints of the forearm?

superior, middle, and distal radioulnar joints

what muscles cause forearm pronation?

* pronator teres
* pronator quadratus

what muscles cause forearm supination?

* supinator
* biceps brachii

MOI → Forearm Contusion

* **Blunt trauma** to the forearm
* Chronic contusion develops from **repeated blows** to the forearm

Signs of Injury → Forearm Contusion

Pain, swelling, and accumulation of blood (hematoma)

Care → Forearm Contusion

* **POLICE** for 20 minutes every 1.5 waking hours, followed the next day by **cold and exercise**
* **Padding** to prevent subsequent blows to the area

MOI → Forearm Splints and Other Strains

repeated static contractions

Signs of Injury → Forearm Splints and Other Strains

* **Dull ache in the extensor muscles** crossing the back of the forearm
* **Muscle weakness**
* **Deep pain** with palpation

Care → Forearm Splints and Other Strains

* Treatment of symptoms
* **Strengthening** of forearm through resistance exercises
* **Rest, cold or heat**, and use of a **supportive wrap** during activity

MOI → Forearm Shaft Fractures

blow or fall on the outstretched hand

Signs of Injury → Forearm Shaft Fractures

pain, swelling, deformity

Care → Forearm Shaft Fractures

* **Cold pack** must be @@**applied immediately**@@ to the fracture site
* **Splint above and below fracture**, and support the arm
* @@**Refer**@@ for x-ray

MOI → Colles’ Fracture

* FOOSH with an extended wrist, forcing the forearm **backward and upward into hyperextension**
* **Distal fracture fragment is displaced backward**

Signs of Injury → Colles’ Fracture

Visible deformity, extensive swelling and discoloration

Care → Colles’ Fracture

* Splint, apply ice, sling the arm
* Refer for x-rays

the wrist is formed by the _____

%%distal aspect of the radius & ulna%%

→ **proximal row of 4 metacarpal bones**

→ **distal row of 4 carpal bones**

→ **articulate with 5 metacarpals**

what forms the metacarpophalangeal (MCP) articulations?

the metacarpal bones that joint the **carpal bones above** and the **phalanges below**

The four fingers each have a _______, ____ __,__ _______ phalanx

proximal, middle, and distal

the thumb only has ____ phalanges

2

what are the joints of the hand/wrist

* Distal radioulnar
* Radiocarpal
* Intercarpal
* Carpometacarpal
* Metacarpophalangeal
* Interphalangeal (Proximal and Distal)

what are the key assessment points for hand/wrist injuries?

* history of **frequent gripping** or other activities that **pull on or bend the fingers**
* observe the **athlete’s willingness to use their hand**
* **observe fingernails** (color, texture, shape)
* **palpate all sides!**

MOI → Wrist Sprains

* Any @@**abnormal, forced movement**@@ of the wrist
* Falling on the **hyperextended** wrist
* Violent **flexion or torsion**

Signs of Injury → Wrist Sprains

* Pain, swelling, and difficulty moving the wrist
* Tenderness, swelling, and limited range of motion

Care → Wrist Sprains

POLICE, refer, rehab, support

MOI → Wrist Tendinitis

Repetitive wrist **accelerations and decelerations**

Signs of Injury → Wrist Tendinitis

* Pain with use or pain in passive stretching
* Tenderness and swelling over the tendon

what is another common condition associated with wrist tendinitis?

tenosynovitis

How many nerves and tendons associated with carpal tunnel syndrome?

9 tendons

1 nerve

MOI → Carpal Tunnel Syndrome

repeated wrist flexion or direct trauma to the anterior aspect of the wrist

Care → Carpal Tunnel Syndrome

* **conservative treatment** initially
* persistent, recurrent symptoms

MOI → Scaphoid Fracture

FOOSH

Signs of Injury → Scaphoid Fracture

* Swelling in the carpal are
* Severe point tenderness over the scaphoid bone in the **anatomic snuffbox**

MOI → Hamate Fracture

contact while an athlete is holding an implement (bat, racket, stick)

Signs of Injury → Hamate Fracture

* Wrist pain and weakness and point tenderness
* Tingling, numbness, and weakness in the **little and ring fingers**

Care → Hamate Fracture

* **Casting** of the wrist
* The hook of the hamate can be protected with a **doughnut pad** to take pressure off the area

MOI → Wrist Ganglion

repeated forced hyperextension of the wrist

Signs of Injury → Wrist Ganglion

* Ganglions generally appear on the back of the wrist
* Occasional pain and a lump at the site
* **Pain increases with wrist extension**

Care → Wrist Ganglion

* **Aspiration and chemical cauterization**, with subsequent application of a pressure pad
* Surgical removal is the most effective way

What is another name for a 5th metacarpal fracture?

Boxer’s Fracture

MOI → Fifth Metacarpal Fracture

* **Direct axial force** caused by punching the wall or another person
* Fractures of the fifth metacarpal are associated with boxing and martial arts (**boxer’s fracture**)

Signs of Injury → Fifth Metacarpal Fracture

* Point tenderness and likely a palpable defect in the shaft of the fifth metacarpal
* Knuckle appears depressed or sunken when making a fist
* Swelling is rapid

Care → Fifth Metacarpal Fracture

Suspected boxer’s fracture should be **referred to a physician** for **reduction and immobilization for a period lasting 3 to 4 weeks**

MOI → Mallet Finger

Blow from a thrown ball that strikes the tip of the finger**, jamming and avulsing the extensor tendon from its insertion**

Signs of Injury → Mallet Finger

* Pain at the distal interphalangeal joint (DIP) sometimes with bony avulsion
* Inability to extend the finger (carrying it at a 30-degree angle)
* Point tenderness at the sight of the injury

Care → Mallet Finger

* **POLICE** for the pain and swelling
* If there is no fracture, the distal phalanx should immediately be splinted in a position of extension 24 hours a day for a period of **6 to 8 weeks**

MOI → Boutonniere Deformity

* Rupture of the **extensor tendon over the middle phalanx**
* Trauma to the tip of the finger forces the **DIP joint into extension and PIP into flexion**

Signs of Injury → Boutonniere Deformity

* Severe pain and inability to extend the DIP joint
* Swelling, point tenderness, and an obvious deformity

Care → Boutonniere Deformity

* **Cold application**, followed by splinting of the PIP joint
* Splinting must be continued for **5–8 weeks**
* Athlete is encouraged to flex the distal phalanx

MOI → Jersey Finger

* Rupture of the @@**flexor digitorum profundus tendon**@@ from its insertion on distal phalanx
* Often occurs in the ring finger when the athlete tries to grab a jersey of an opponent

Signs of Injury → Jersey Finger

* DIP joint cannot be flexed, and the finger remains extended
* Pain and point tenderness over the distal phalanx

Care → Jersey Finger

* Must be surgically repaired
* Rehabilitation @@**requires 12 weeks**@@, and there is often poor gliding of the tendon, with the possibility of re-rupture

MOI → Gamekeeper’s Thumb

* Sprain of the **ulnar collateral ligament (UCL)** of the **MCP joint of the thumb**
* **Forceful abduction** of the proximal phalanx occasionally **combined with hyperextension**

Signs of Injury → Gamekeeper’s Thumb

* Pain over UCL in addition to a weak and painful pinch
* Tenderness and swelling over the medial aspect of the thumb

Care → Gamekeeper’s Thumb

* **Immediate follow-up** must be performed
* If the joint is unstable, athlete should be referred to an **orthopedist**
* If the joint is stable, an **X-ray** should be performed to rule out fracture
* Thumb splint should be applied for protection for **3 weeks or until pain free**

MOI → Phalangeal Dislocation

* **blow to the tip of the finger directed upward** from the palmar side
* displaces either the **first or second joint dorsally**

Signs of Injury → Phalangeal Dislocation

* tearing of the supporting capsular tissue and hemorrhaging
* possible rupture of the flexor or extensor tendon and chip fractures in and around the dislocated joint

Care → Phalangeal Dislocation

* reduction should be performed by a physican
* splint for 3 weeks in 30 degrees of flexion
* inadequate immobilization may lead to instability and/or excessive scar tissue accumulation and possibly a permanent deformity
* finger can be buddy-taped to the adjacent finger for additional support
* special consideration must be given to dislocations of the thumb and second or third joints of the fingers
* any dislocation of the 3rd joint of the finger can lead to complications and requires and immediate care of an orhtopedist
* all finger or thumb dislocations must be x-rayed to rule out fracture

MOI → Phalanx Fracture

the fingers are stepped on, hit by a ball, or twisted

Signs of Injury → Phalanx Fracture

* pain and swelling in a finger
* tenderness at the point of fracture

Care → Phalanx Fracture

* **Splint in flexion** around a gauze roll or a curved splint to **avoid full extension**
* Reduces the deformity by relaxing the flexor tendons
* Fracture of the distal phalanx is generally less complicated than fracture of the middle or proximal phalanx

MOI → Collateral Ligament Sprains

Axial force to the tip of the finger, which produces the “jammed” effect

Signs of Injury → Collateral Ligament Sprains

* Severe point tenderness at the joint site, **especially in the collateral ligaments**
* **Lateral or medial joint instability** when the joint is flexed to 150 degrees